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New Dyce Medical Practice
Evaluation Report
May 2017
Report prepared by the Public Health Research Team (Kalonde Kasengele, Jacqueline Bell,
and Fiona Murray), NHS Grampian Health Intelligence.
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Table of Contents
EXECUTIVE SUMMARY ............................................................................................ 3
1 INTRODUCTION .................................................................................................... 5
1.1 Aims and Objectives ............................................................................................................ 6
2 METHODS .............................................................................................................. 7
2.1 Profile of practice population ........................................................................................... 7
2.1.1 Age......................................................................................................................................... 7
2.1.2 Deprivation ......................................................................................................................... 7
2.2 Data collection and analysis .............................................................................................. 8
2.2.1 Survey sample .................................................................................................................... 9
3 FINDINGS ............................................................................................................ 10
3.1 What was the patient perception/experience of care? ......................................... 10
3.1.1 Summary of findings ..................................................................................................... 10
3.1.2 Care provided by ANPs and PAs ............................................................................... 12
3.1.3 Perceptions regarding continuity of care .............................................................. 12
3.1.4 Comparison with previous surveys .......................................................................... 12
3.2 How effective is the appointment and triage system? .......................................... 14
3.2.1 Patients’ views and experiences ................................................................................ 14
3.2.2 Staff views and experiences ........................................................................................ 16
3.3 Staff Perspectives ................................................................................................................ 18
3.3.1 Understanding the vision and aspirations............................................................. 18
3.3.2 Training and Support Needs ...................................................................................... 19
3.3.3 Perception of ANP/PA role ......................................................................................... 20
3.3.4 Continuity of care ........................................................................................................... 21
3.4 What improvements could be made? ......................................................................... 22
3.4.1 Patient views .................................................................................................................... 22
3.4.2 Views from staff members .......................................................................................... 23
3.5 What impact has this new of working had on workload and referrals? ......... 25
3.5.1 How do workloads vary by staff group? ................................................................ 25
3.5.2 How have workloads changed? ................................................................................ 27
3.5.3 How have referrals changed? ..................................................................................... 28
3.5.4 Emergency admissions data ....................................................................................... 29
4 CONCLUSION AND RECOMMENDATIONS ...................................................... 31
APPENDICES ........................................................................................................... 32
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EXECUTIVE SUMMARY
Background
In October 2015 a new GP practice was established in Aberdeen that uses a new
model of primary care, introducing a wider multidisciplinary team: physician
associates (PAs), advanced nurse practitioners (ANPs) and pharmacists working
alongside the GPs and practice nurses. The purpose of this evaluation was to
understand the effects of this new way of working on patients, staff, and interaction
with wider healthcare systems.
Methods
The study was conducted between August and October 2016. A mixed-methods
approach was used, that comprised: focus group sessions with the different staff
groups and one for patients with long-term conditions; a patient survey; data from
the practice IT systems; and secondary care data.
Findings
Patient perceptions of care
Most patients reported they were satisfied with the care they received at New Dyce,
with 80% rating it as good or very good. Elements of patient consultations were
rated well, including: receiving clear explanations of their condition and treatment
(72%); feeling involved in decisions about their care (69%); having sufficient time
(60%); confident in the knowledge shown by professionals (75%) and the advice or
treatment provided (66%). Moreover, 83% of patients felt that their issue had been
dealt with by the right person. While there were reservations about the new model
among those who had not received care from ANPs and PAs, those who had
consulted these health professionals expressed higher levels of contentment. Some
patients felt that continuity of care had diminished as a result of the changes.
How effective is triage and the appointment system?
The current system is problematic, for both patients and staff. The main issues relate
to lack of clear guidelines and administrative staff having to make decisions that may
be more appropriately made by clinical staff. Most staff groups expressed a strong
preference for the introduction of an effective triage system, and the vision of the
management team is to create a system where clinicians get involved at an early
stage. In addition, many felt there was a need to educate patients about the new
roles within the practice team
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Staff perspectives
Overall the attitude of staff to the new way of working was very positive with a
forward-looking approach and willingness to find opportunities to improve and
develop the service. There was a general consensus that patients were becoming
more accepting of the new workforce, and increasingly were requesting to see
ANPs/PAs.
Staff workload
The monthly number of patient contacts made by GPs, ANPs and PAs has increased
from 3,930 in January 2016 to 5,362 in January 2017, despite the full time equivalent
(FTE) by clinical groups remaining fairly constant. An increasing proportion of GP
activity is now devoted to surgery consultations (35% at the start of 2016 to 60% in
2017). There has been a shift of administrative activities, telephone calls with
patients, triage and home visits to the other professionals. ANPs conduct most of the
home visits, pharmacists cover all of the medicine management and PAs conduct
most of the telephone contact with patients.
Secondary care
The total number of referrals has been increasing steadily from 300 in November
2015 to nearly 400 in January 2017. While there was an increase in the number of
emergency admissions to ARI in the months immediately before and after the
establishment of New Dyce, these levels appear to have returned to former levels.
Conclusion and recommendations
The response from the evaluation has been generally positive, with high levels of
satisfaction from both patients and staff. This suggests that things are moving in the
right direction after a very challenging beginning. The main areas for improvement
suggested by patients and staff were about having better arrangements for “getting
through” to the surgery and having a clear, visible triage system. Sensitive, person-
centred communication was a particular issue raised by patients. A full list of
recommendations and valuable lessons are made on page 31.
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1 INTRODUCTION
New Dyce Medical Practice started as a new entity on 1st October 2015, taking over
the GMS contract for 10,000 local patients previously cared for by Brimmond Medical
Group and Gilbert Road Medical Group. A few reception staff and 2 senior nurses
from the outgoing practices provided some continuity of care for the patients, but
otherwise all 10,000 patients and all clinical staff were new to each other - a unique
position in British general practice. The need for this new practice was partly due to
the recruitment crisis in general practice, and as a result, at the outset the permanent
clinical staff included 2 part-time salaried general practitioners (GPs), 3 advanced
nurse practitioners (ANPs), 2 physician associates (PAs, a new role in primary care)
and 2 pharmacists.
The new practice arrangement was described in the local press, and several public
meetings were held to provide information and answer questions. Scotstown Medical
Group provided the management expertise and several senior general practitioners
to help support the initial working of the practice. The team understood that
patients may have concerns about the change after several decades of medical care
in two established medical practices.
Acknowledging it would be a 5-year programme to fully establish the practice, the
initial aim was to provide timely access to a clinical member of the team for patients
presenting with urgent medical problems. It is for this reason reception staff were
advised to invite patients to tell them about their problem, the urgency of that
problem and then offer an appointment to a suitably qualified member of the clinical
team. The patients were informed at public meetings, by newsletter and when
requesting appointments that they would see a GP or another member of the clinical
team who was directly under the supervision of a GP. The aim of this early model
was to provide prompt access for face to face consultations with the clinical team. As
the practice matured it was accepted that this model would evolve further with
effective, clinician-led triage in the future. Continuity of care for those with longer-
term conditions would inevitably take time to develop.
New Dyce was keen to capture staff and patient views of this early innovative work
and therefore approached the IJB and Health Intelligence Unit to commission a
survey to help understand and reflect on this evolving family practice.
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1.1 Aims and Objectives
The purpose of the evaluation is to understand the effects of this new way of
working on patients, staff, and interaction with wider healthcare systems. In the
short-term, it will provide a description of the process of change and the context in
which it is being implemented, highlighting areas requiring attention. With regular
long-term follow-up, this work will provide the basis for future impact evaluation and
process evaluation that will help to inform and influence the developing nature of
primary care practice to increase resilience, sustainability and effectiveness. The main
questions of interest from the practice’s perspective are:
What is the patient perception/experience of care?
How effective is appointment and triage system?
What is the staffs’ perspective? Are they engaged and do they have a vision for
the practice?
What improvements could be made?
What impact has this new of working had on workload and referrals?
On the basis of this the objectives are to:
1. Describe patient awareness, experience & satisfaction with using the service
2. Describe staff/practitioner experience & satisfaction with providing the service
3. Describe patterns of service use – including practitioner workloads, in and out
of hours, referral patterns, consultation/diagnostic changes, A&E attendances,
emergency admissions
4. Identify ideas for improvement that can be implemented in an action cycle.
Some of these data will provide indicators that can be measured again in 12 months
and used as evidence to demonstrate effectiveness of interventions.
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2 METHODS
2.1 Profile of practice population It is important to get an understanding of the Practice population in order to
contextualise the findings.
2.1.1 Age
On average, the age profile of the New Dyce Medical Practice population is older
than the overall Aberdeen GP registered population (see Figure 2.1 below).
Figure 2.1: New Dyce and Aberdeen City GP registered population by age 2016 (%)
2.1.2 Deprivation
As illustrated in Table 2.1 below, New Dyce patients are more affluent compared to
the Aberdeen GP registered population. For example, over three quarters of New
Dyce patients were in the two most affluent SIMD quintiles, with none being in the
most deprived and second most deprived quintiles.
0
1
2
3
4
5
6
7
8
9
10
0-4
5-9
10
-14
15
-19
20
-24
25
-29
30
-34
35
-39
40
-44
45
-49
50
-54
55
-59
60
-64
65
-69
70
-74
75
-79
80
-84
85
+
Aberdeen New Dyce
8
Table 2.1: SIMD1 distribution of New Dyce Medical Practice compared to Aberdeen City
1 (most deprived 2 3 4 5 (least deprived)
New Dyce (10,097) 0.0 0.0 23.1 32.6 44.3
Aberdeen 12.3 17.0 15.2 16.2 39.3
1SIMD 2012 quintiles used
2.2 Data collection and analysis
A mixed-methods approach was used to understand this new way of working. The
target groups for qualitative work comprised staff members and patients attending
services at New Dyce. Staff members and all patients attending the Practice between
August and October 2016 had an equal opportunity to participate in this evaluation.
Patients were informed about the survey by posters at reception and staff members.
Using an opportunistic approach meant that all patients attending the Practice had a
chance to complete a questionnaire, either on a Viewpoint machine or on a paper
form after their appointment. A decision was taken not to conduct a postal survey in
order to obtain information on patients’ recent experiences of the service. Data were
gathered using a variety of methods:
Five focus group sessions with different staff groups (administration,
PAs/ANPs/pharmacist, GPs, practice nurses, and the management team) and
one for patients with long-term conditions.
A patient survey (see Appendix 1) to understand experiences, satisfaction and
to generate suggestions for improvement. The questionnaire focused on the
appointment attended that day and asked about their experiences making the
appointment and during the consultation.
Quantitative data were gathered from GP IT systems to review workloads and
referral patterns. This was augmented with secondary care data from Trakcare.
A comparison was made between responses to the patient survey and the
most recent Health and Care Experience survey reports available for Brimmond
(158 patients in 2013/14) and Gilbert Road Practices (110 patients 2015/16)
Qualitative data from the written responses of the survey and focus groups were
transcribed and analysed thematically. Quantitative data were analysed using Excel to
produce summaries of patient responses and investigate patterns by
demographic/clinical background of respondents. Ethical approval was not required,
as this work was for service improvement.
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2.2.1 Survey sample
Among the group of respondents, women and older people were over-represented
compared to the Practice population as a whole, which is probably a reflection of the
sub-groups most likely to attend. Over 95% of respondents came from Brimmond or
Gilbert Road Practices.
The professionals seen by the survey respondents are shown in Table 2.2. Very few
had seen PAs (10) or the pharmacist (5) at their last appointment, meaning it was not
possible to do sub-group analysis in this respect.
Table 2.2: Professional seen by respondent prior to completion of the survey
Professional N %
GPs 61 26.3
ANPs 58 25.0
PAs 10 4.3
Pharmacists 5 2.2
Practice Nurses 70 30.2
Not sure 9 3.9
Missing 19 8.2
Total 232 100
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3 FINDINGS
3.1 What was the patient perception/experience of care?
The majority of respondents were satisfied with the care they received at
New Dyce, 80% rating it as good or very good
3.1.1 Summary of findings
Most patients reported having a good experience in their consultation including:
receiving clear explanations of their condition and treatment (72%); feeling involved
in decisions about their care (69%); having sufficient time (60%); and confident in the
knowledge shown by professionals (75%) and the advice or treatment provided
(66%). Moreover, 83% of respondents felt that their issue had been dealt with by the
right person, and this was similar across the professional groups seen (GPs, ANP, PAs,
pharmacists). Those who were not sure who they had seen were the least likely to
respond positively (only 46%). Patients’ rating of the care they received is illustrated
in Figure 3.1 below.
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26.3
35.3
24.1
36.6
29.7
30.2
52.2
30.6
37.1
34.5
38.4
39.7
35.8
27.6
12.5
10.3
12.9
5.6
9.9
10.3
9.5
10.8
2.6
6.9
3.4
3.4
3.9
2.2
6.5
3.4
5.2
3.9
2.2
3.4
3
13.4
11.2
16.4
12.1
15.1
16.4
5.6
Sufficient time to discuss my health/medical issue
Explanation of condition and/or treatment in a way that could be understand
Being given the right amount of information
Confidence in the knowledge shown by the professional(s)
Feeling involved in decisions about care
Confident in the advice/treatment provided
Overall rating of the care provided by the team
Very positive Positive Neutral Negative Very Negative Missing
Figure 3.1: Patients’ rating of care provided
3.1.2 Care provided by ANPs and PAs
Fifty-seven percent of respondents felt content with the idea of an ANP providing their
care, and 43% were content with a PA providing their care. The approval ratings were
higher among patients who had seen either an ANP or PA at their last appointment (81%
of those who had seen an ANP were content with ANP care and the corresponding figure
for PAs was 60%). This highlights a key issue in that whilst there were reservations
amongst those who had never received care from ANPs and PAs, their contentment
generally increased once they had experienced care from these health professionals. For
some, ANP and PAs were a good addition to the practice because they were able to
provide more thorough examinations:
“When seen by ANP/PA I find them to be very thorough. They examine you and
check your vital signs.”
3.1.3 Perceptions regarding continuity of care
Surprisingly, very few respondents appeared to understand the reasoning behind the
practice restructuring, which may explain why a number of patients were asking for their
old doctors back. However, it was not purely “mourning” a loss of the doctors who had
treated them for many years, but a strong feeling that continuity of care had diminished
as a result of the change:
“It's not good at all. We've lost all our doctors. No one told us this would happen.
Now seem to be all part time staff. No continuity.”
“Not great as every time you visit it is with a different doctor, whereas before
you more or less could get to see the same doctor who knew all about your
illness.”
“Feel the service provided is much poorer than the service my family received
prior. Wait times/booking-in frequently broken making you 'late' for your appt
as you've had to queue for 10 mins to get checked in. 3 wks until you can book
an appointment. Rarely can see same doctor twice = poor continuity of care.”
3.1.4 Comparison with previous surveys
Although patients were generally positive about their experience of care, they seem
slightly less content than they were in their previous practices. The evidence for this
comes from the Health and Social Care (H&SC) survey reports for Brimmond and Gilbert
13
Road practices (see Appendix 2), where positive ratings on certain aspects of
consultations were higher than in the current evaluation. For example in the New Dyce
survey 57% responded positively to the statement “Sufficient time to discuss my
health/medical issue” while in the H&SC survey over 90% reported having enough time
with doctors or nurses. Similarly, the overall care provided was rated positively by 80% in
New Dyce compared to the earlier H&SC survey where positive ratings for Brimmond and
Gilbert Road were 90% and 92% respectively. It is noteworthy that questions were not
worded identically in the two surveys, and that in New Dyce the relationships between
respondents and GPs were relatively new, both of which may contribute to the variation
in responses.
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3.2 How effective is the appointment and triage system?
The current system is problematic. The main issues relate to lack of clear
guidelines and Admin staff making decisions that would be more appropriately
made by clinical staff.
3.2.1 Patients’ views and experiences
Patients’ experiences of making an appointment came through as a significant issue,
particularly in relation to the telephone system. Just over half the patients making an
appointment got through to the practice on their first attempt whilst 15% had to make 5
or more attempts. This was reflected in the open ended-questions when participants
were asked for improvements:
“Before the practice changed you just dialled straight through. But now you have
to go through all this spiel which is just a waste of time & money”
“To change the phone answering system as when you want an appointment that
day - the machine says to call back when less busy - I called 28 times.”
Almost 60% of respondents reported seeing a clinician in less than two days of making
an appointment, 37% of these being seen within a day. At the other end of the scale, 12%
were seen after more than a week. Over 80% of respondents found the wait until an
appointment was available either “acceptable” or “very acceptable”. This also came
through in the open ended questions where participants were asked how the service
compared with that on offer prior to the restructuring:
“Improved - quicker to get through by phone, quicker to be seen, time allowed to
discuss things not too rushed.”
“Up until this point in time it is very much improved. I find appointments don't
seem to have a waiting time. Service has been excellent compared to having to
wait sometimes more than a week to see someone.”
Unsurprisingly, those who waited for more than a week were most likely to find it
“unacceptable” or “very unacceptable”. It is noteworthy however that a quicker
appointment did not necessarily mean patients got what they wanted. Whilst there was a
general appreciation that appointments with ANPs and PAs were more readily available,
there was also a sense of frustration amongst patients that they now felt it was more
difficult to see a GP.
15
“More available appointments with doctors. I was initially offered appointment
in 2 weeks with doctor and over 1 week for ANP - not great when you have
health concerns.”
“Poor. Like digging for gold to get past reception to GP appointment”
Importantly, despite 83% of patients stating that their issue had been dealt by the right
person, fewer (67%) felt that the decision over who they saw had been made in an
appropriate way. Those who were critical (18.7%) were asked for their reasoning. Key
themes from their written responses are presented below.
At the heart of it was an underlying “discomfort” discussing medical conditions with
reception staff. Some felt that the reason for their appointment was “none of their
business” and others questioned how receptionists with no medical training could make
such “important” decisions:
“How does a receptionist decide if it is a doctor or NP you see. I would like to
know if they are medically knowledgeable to decide.”
“Decisions are being made by people who are not medically qualified.”
Patients’ uneasiness about dealing with receptionists was not limited to them making
decisions on which clinicians they should see; some did not understand why they were
also involved in giving out test results:
“Let patients know test results - good or bad instead of having to phone up and
ask and get the results from receptionist instead of GP.”
Another recurring theme was a feeling of not being involved in the decision-making
around which health professional they saw. Common assertions were that they had either
not been given a choice or they had not understood how the decision was made.
Interestingly, as seen in the second account below, this uncertainty was sometimes
present amongst those who had experienced a good outcome.
“I was not consulted or given a choice.”
“I don't know how the decision was made. Outcome was fine though.”
This suggests a breakdown in communication where patients were either not
understanding what was being said or the information was not being explained clearly, if
at all. A big part of this for patients was about being listened to:
16
“They didn't take into account what I wanted. I didn't feel they were listening to
me. They just cut you off and talk over you when you phone for an
appointment.”
This highlights an important point, that a number of patients simply did not understand
why they could not see a GP if they wanted to. Another emerging theme was a concern
by patients that ANPs and PAs were being “passed off” as GPs by receptionists and the
practitioners themselves.
“Staff at reception have a tendency to dictate who you need to see based on
who they have available, as opposed to who you need to see. They try to pass off
[A]NPs and PAs as GPs.”
“It should be made clearer which professional you are actually seeing. Only
when we asked did she divulge she wasn't a GP.”
3.2.2 Staff views and experiences
The management team described triage as “currently in its infancy” where it was simply
operating as means of signposting patients to an appropriate member of the team.
However, it was emphasised that the vision is to create a more robust and detailed triage
system where clinicians get involved at an early stage and can, in some instances, deal
with patients over the phone to avoid them coming in to see a clinician if it is not
necessary. There have been mixed experiences thus far, with patients having positive
experiences and other instances of patients seeing the wrong health professional.
Management highlighted that one problem is the “out and out refusal” of patients
engaging with “just a receptionist” who is asking what they deem to be personal
questions. As illustrated below, this can lead to wasted appointments:
“Receptionists just ask for the – “nature of the problem” so they are not delving
in anything they shouldn’t but some patients do put a barrier and say no which
makes it difficult for the Reception Staff to make sure the patient sees an
appropriate Clinician. So there has to be some responsibility born by the patient
since they take an appointment because time suits them or by not engaging
then they may end up with someone who can’t deal with the problem presented.
This leads to a wasted appointment and a waste of the patients’ time.”
Amongst the reception/ administrative team, there was a general consensus that the
most difficult period was in October 2015 during the transition to New Dyce. Those who
had been in post during that time recalled how it was “very challenging” fielding
questions and angry calls from patients. There was agreement that the situation had
17
improved immensely and there was a great sense of relief that they got through that
initial period.
Reception/administration staff advised that they were learning about the roles of ANPs
and PAs (and their different areas of particular expertise) in order to better signpost
patients. They also felt that patients are becoming more confident with PAs and ANPs:
“We find out what the problem is so we can decide where to put them. For
example, if it’s contraception they go to an ANP – they all have their own little
roles that they do.”
ANPs, PAs and pharmacists asserted that they do not have much involvement in triage
and have no control over who they see.
“As of yet decision-making as to whether someone needs to come in and be seen
is very ad hoc.”
On the whole, they felt having a clinician on the telephone line to triage patients could
make a big difference to determine how many patients actually needed to be seen in
person because administrative staff could not make this decision.
Practice nurses said the receptionists have to enquire about the nature of the ailment,
but some patients get sent to the ANP rather than a prescribing practice nurse. They also
felt that there were not enough practice nurse appointments, so patients saw the ANP
when it was not really necessary.
There was a dominant view amongst GPs that a “proper triage system” could make great
improvements in the use of the workforce. If triage was good, they felt the practice could
use PAs to confirm the triaging doctor’s initial impression and save GPs patient contact
time. There was recognition that some patients are more complex and clearly need to be
seen by a GP (e.g. those with a complex mental health situation). They also felt that non-
clinically trained staff members were not qualified to triage effectively and this was
leading to patients being allocated according to availability of appointments rather than
clinician ability. Denburn and Danestone practices were given as examples of “triage that
works” since everything is triaged by GPs in the morning by phone. It was recognised this
would initially mean extra work for the GP team. In addition, they felt there is a need to
educate patients about what other roles within the practice team can do. GPs are
currently making a note of any appointments for consultation they feel have been
inappropriate. It was also felt that admin staff could take on some of the initial sifting and
paperwork currently undertaken by PAs if provided with appropriate training.
18
3.3 Staff Perspectives
Whilst there was not a written vision, staff members have bought in to the idea
that this is a new, and still evolving, way of working in GP Practice. Overall the
attitude was very positive with a forward looking approach, finding
opportunities to improve and develop the Practice team.
The majority of reception/administrative staff had had come from Brimmond Practice.
Most of the practice nurses also had many years of experience with Gilbert Road and
Brimmond Practices. ANPs PAs and pharmacists had a range of experience from working
in surgical secondary care to decades of experience in various primary care settings. The
GPs were all relatively newly qualified and remarked that the ANPs at New Dyce take on a
wider range of work than at other practices they had experienced and working with PAs
in general practice was a new experience.
3.3.1 Understanding the vision and aspirations
Unsurprisingly, the management team had the clearest understanding of the direction
for New Dyce. They saw it as a practice that was bringing together a range of clinicians to
help support GP services, consequently forming a workforce that can look after the
service needs of the Dyce population. They wanted to “develop a Practice that is
sustainable for the future given the pressures that primary care is under”. They saw the
administrative team as being central in this model as they were the first point of contact
and would thus help guide patients through that initial triage. The New Dyce model will
be dynamic as it will need to evolve over time, but will become the “Go to” model for
patient delivery and will be sighted as best practice. They also felt there was a need to
share the vision with patients and help them understand that GPs were a finite resource
due to increased shortages.
Reception/administrative staff felt they understood the New Dyce Medical Practice
would be structured differently and this had been explained to them. How things will
evolve over the next few years was less clear in their view and there was an acceptance
that “time will tell”. Nevertheless, there was agreement amongst the team that things
were generally going well with some asserting that it was “quite exciting”:
“it’s going quite well at the moment I think with the PAs and stuff. It’s new to
people so it’s getting them used to it”
19
Practice Nurses felt they understood the vision – that it was to be a multi-disciplinary
approach, very much patient centred. They felt that patients were coming around to an
understanding of the new way of working and not seeing a GP every time. They felt that
patients are accepting of this and like the fact that they are seen by a practitioner more
quickly, but they need to know there is always a duty doctor around who can be called
on if necessary.
“This way is easier – you always know there’s another nurse you can ask for their
opinion or the duty doctor or another colleague. Previously you’d be working on
your own. Here there’s not the hierarchy there was at my previous practice. This
leads to better patient care as they get an answer and don’t have to come back
to see another person another time.”
The ANPs, PAs and pharmacists were less clear regarding the vision, but recognised
that they were a central part to this new way of working:
“None of us knows what it might mean. Up to July it was fire-fighting, but it
feels a bit more settled now.”
“Don’t feel we’d be got rid of even if there were to be a boundless supply of
GPs”.
GPs commented that the GP team is young, with less experience than the practices
patients had come from, but it is very forward-looking and ambitious (e.g. one GP
expressed a wish for the practice to win an award for “Innovation in General Practice”).
Another GP hoped there would be more engagement with neighbouring practices and
closer linking with secondary care. As an effectively semi-rural practice, taking in Fintry
and Newmachar, it was hoped there might be opportunities to apply for equipment
funding on this basis, possibly with neighbouring practices, thus avoiding some referrals
into secondary care.
3.3.2 Training and Support Needs
Reception/ administrative team suggested they would benefit from further training in
use of the Vision system. Initially they had a little bit of training and had found it very
difficult. Some have been peer training among themselves. They felt they work together
and support each other well.
PAs, ANPs and pharmacists had not had discussions on training, but said some of the
newly arrived GPs have started to look at areas of interest and how the practice all fits
20
together. They advised that there is no learning programme currently, but some felt they
had more on-the-job learning at New Dyce than at their previous practices. They felt they
do a lot of clinical admin which probably was not good use of their time, but there had
been improvement around work with blood reports. This group also felt the cover for
staff absence/ holiday was a problem:
“Basically it’s all waiting for you when you get back from holiday – no locums or
additional help.”
Practice nurses said they have been encouraged to attend training since arriving in the
practice and currently have “lunch and learn” sessions with more planned.
GPs plan to set up support meetings e.g. to discuss problematic patients. With more
permanent GPs and less reliance on locums now this can progress. Personal training and
development is almost entirely self-directed, but management is keen on a group-based
learning.
3.3.3 Perception of ANP/PA role
There was a view amongst staff members that the first few months of the transition had
been difficult for patients, largely because of poor understanding of the ANP and PA
roles. However, there was a general consensus that patients were becoming more
accepting of this new workforce. Increasingly, patients (particularly regular attenders)
were calling in requesting to see the same ANP/PA that had previously attended to them.
PAs and ANPs acknowledged that, initially, they needed quite a lot of reassurance and
this led to them requesting for GP assistance in most cases. However, they advised that
the need for help has reduced significantly due to increased confidence and experience
in their roles. One ANP felt that having “nurse” in their job title meant they were
perceived as more approachable than the GP – some patients now say “So I’ll just see you
then” in a very positive way.
The fact that ANPs can prescribe was seen as a considerable advantage because it
allowed them to work more independently and take on additional responsibilities. One
staff member described them as being like “another doctor” because they could just “get
on with the work”. PAs were seen as being good at what they do (particularly
examination skills and history taking) but there was general agreement that they were
restricted because they could not prescribe, and consequently almost always have to
consult the duty doctor. This was a source of frustration to patients, PAs and other staff
members as it often led to delays in consultations.
21
3.3.4 Continuity of care
Reception/ administrative team thought it was particularly challenging for elderly
patients as they previously had the same doctor for years and it is difficult for them to
understand that they would not always get a particular doctor. This was also the case for
chronic patients who prefer to see the same clinician.
Practice nurses said some patients request them by name, and whilst this is good for
continuity of care, if someone else sees one of “your” patients they might pick up
something different and suggest an alternative treatment plan. Additionally, when
dealing with complicated patients sometimes it is good to “share the pain” so an
individual is not always “lumbered” with them.
GPs felt that with lots of locums initially it was difficult to be consistent, but this was
improving because now patients were able to ask to see one of the newly appointed GPs
by name.
Management team said the patients who find it challenging are those with long term
conditions who are looking for continuity of care. With 22 doctors involved since the
practice started in October 2015, there has not been a good base to offer good
continuity, but that has changed recently with due to an increase in the number of
permanent doctors who have joined. Palliative care has generally been good as there has
been good continuity with the district nurses.
22
3.4 What improvements could be made?
3.4.1 Patient views
The main areas of improvements for patients and staff members included
simplifying the telephone system, a better mechanism for allocating patients to
appropriate clinicians, the reception area, IT system (including self check-in),
continuity of care, training opportunities, and communication between different
staff groups. There were some similarities and differences in suggestions for
improvements between views of patients and staff members.
When asked what improvements could be made to the Practice, patients identified a
number of areas which they felt could be better. The main suggestions included
simplifying the telephone system, having a better mechanism for allocating patients to
appropriate clinicians, and continuity of care (see discussion above in sections 3.1.3 and
3.2.1). Another important enhancement concerned the reception area as whole. Firstly,
there was a recurring view that reception staff needed more training to improve their
customer service skills and become more welcoming. The glass barriers seemed to
exacerbate this view:
“Reception staff require customer service training...Put a bell/buzzer at reception
so patients are not routinely ignored by staff...”
“...Feel receptionists quite unhelpful with alternative solutions/ slow to respond
at window -leave patients standing.”
“Training for receptionists - not as friendly or polite as we previously had at
Gilbert Road. Need new phone system.”
Secondly, the waiting area was seen as plain and requiring some light entertainment
while patients waited for their appointment
“Very happy about all the care. Reading material and tv in reception.”
Lastly, it was also suggested that there should be profiles of staff in the waiting area to
make it easier to identify the different health professionals and their different roles
(especially in relation to ANPs and PAs)
“I would like to see notices on the walls - describing the types of staff you can
see and what you would recommend we see them for. This would give me more
confidence.”
23
For others, they did not believe there was much that could be improved as they were
receiving a high level of care and took the view that the model adopted by New Dyce
Medical Practice would soon become the norm:
“Very lucky to have the level of care provided. It is probably the future of GP
practice and provision; don't see why other health care providers shouldn't take
up other treatments etc.”
Views from the focus group of patients with long-term conditions were consistent with
the variety of views that came through the written responses. For example, when asked
regarding continuity of care, two of the three participants had not seen any difference to
before the change in October 2015 because their appointments were fairly routine. The
third participant on the other hand felt that it had become a “flip of the coin” who
attended to them which had made it difficult to build a “doctor-patient relationship”.
3.4.2 Views from staff members
The main areas of improvements for staff members were the telephone system, reception
area, IT system (including self check-in), training opportunities, and communication
between different staff groups. There were some similarities with patients in relation to
improving the telephone system and reception area. For example, staff members also felt
that they telephone system could be simplified, with some suggesting that changing the
“03” to a local number may help remove the perception that they were calling a premium
number.
They also suggested having some music and/or TV in the reception. This was not only to
keep patients occupied but also to reduce the chances of patients listening in to other
patients’ conversations. There was general agreement amongst staff that the reception
area is very exposed and there is some risk to patient confidentiality. As illustrated below,
one staff group highlighted how they could hear conversations from a distance:
“We can hear what’s being said at the window right across the waiting area.”
With regards to IT, even though it was acknowledged that it had improved considerably
since the early stages of the transition, it was still seen as an area that could do with
significant development. For example, multi-stations were suggested for
reception/administrative staff as the best solution to avoid the need to move people
around. Furthermore, there was a dominant view that the self check-in service needed a
major upgrade or replaced altogether. This was because it hardly worked at all and it was
difficult to use. Some staff groups felt that it was poorly set up because the health
24
professional’s name would come up on the screen rather than the patient’s name. This
was challenging in that patients may not know who they are seeing. That is, they may
know that they have come to see “the nurse” without recognising the clinician’s name. As
a result, it often led to long queues in reception and clinicians having to come in to check
if their patient had arrived.
Communication between staff groups and the wider communication between the
Practice and patients was another key area of improvement. With respect to the former,
suggestions included having weekly meetings to raise issues and discuss ideas that staff
members had. Moreover, there was a feeling that communication between clinical and
reception/administrative staff was in need of improvement and that both sides had to
work together to find suitable solutions. In addition, it was also suggested that PAs and
ANPs needed a more dynamic working relationship with GPs in order to make sure they
are getting the most out their role and their strengths are being made use of. In relation
to communication with patients, a quarterly or biannual newsletter was suggested to
keep them informed of developments in the practice (e.g. short articles on self care, new
staff members joining the Practice etc).
Improvements relating to training opportunities (see section) and triage have been
discussed in detail above (see sections 3.3.2 and 3.2.2 respectively). With regards to the
latter is important to highlight that, whilst there was general agreement that triage would
be better handled by clinicians (especially GPs), some did emphasise that this should still
be through a call back system. Their reasoning was that clinicians undertaking telephone
triage at the time the calls came in might not be a good use of their time because they
believed that about 80% of the calls the reception staff can deal with perfectly well. GPs/
PAs/ ANPs could do a “call back” for the remaining cases that needed input from
clinicians.
Finally, there were some suggestions that recruiting additional practice nurses would be a
good use of resources and the Practice could still adapt further to include, for example,
physiotherapy alongside the ANPs and PAs as part of the team. Minor surgery was
mentioned positively as a future development, along with evening surgeries.
25
3.5 What impact has this new of working had on workload and referrals?
The monthly number of patient contacts1 made by GPs, ANPs and PAs has
increased from 3,930 in January 2016 to 5,362 in January 2017 despite clinical full
time equivalent (FTE) remaining fairly constant. An increasing proportion of GP
activity is now devoted to surgery consultations (35% at the start of 2016 to 60%
in 2017). There has been a shift from administrative activities to the other
professionals, including telephone calls with patients and home visits. ANPs carry
out most of the home visits, pharmacists cover all of the medicine management
and PAs conduct most of the telephone contact with patients.
Since October 2015 the FTE by professional group has remained fairly constant, with
about two ANPs, two PAs and two pharmacists. The total FTE for GPs has been about 4.0,
with increasing stability as salaried GPs have been employed, and the input from locums
and Scotstown partners has been reduced. The workload assessment was based on a
listing of activities, with equal weight given to each activity; this means that reported
percentages do not necessarily reflect the amount of time spent in each activity.
3.5.1 How do workloads vary by staff group?
The most recent figures from January 2017 (see Figures 3.2 and 3.3 below) show that GPs
workload is mainly split between surgery consultations (74%) and recording and
interpreting results (21%), with the remaining 5% of their activities comprising
administration, telephone calls with patients and home visits.
In the same month, ANPs workload was split between surgery consultations (68%),
recording results (18%) and home visits (11%), with a small amount of administration and
telephone calls. The PAs workload was split between recording and interpreting results
(61%), surgery consultations (16%), telephone calls with patients (12%), administration
(11%) and. The amount of results recording completed by PAs was in fact higher than
these data suggest, as they often covered the initial interpretation of results for locum
GPs. The pharmacists’ work is predominantly medicine management, over 90% most
months. Over 95% of practices nurses’ workload is surgery consultations every month.
1 Patient contacts comprise: surgery consultations, home visits, clinics and telephone calls
26
Figure 3.2: Comparing workload by professional group and activity1, January 2016 and January 2017 (numbers of activities)
Figure 3.3: Comparing workload by professional group and activity1, January 2016 and January 2017 (percentages of activities)
1 Activities given equal weight so the distributions do not necessarily reflect the amount of time spent in each activity
27
Focussing on differences in the work of GPs, ANPs and PAs, GPs conducted the majority
of surgery consultations (2,593 in January 2017, which is 74% of the total). In
comparison the ANPs did 10% and the PAs, 4%. GPs also shared the results recording
with PAs. The ANPs did the majority of home visits, 76 (84%), with the remainder
conducted by GPs. The PAs did more administration than the other two groups (55% of
the total) and conducted 80% of the telephone calls with patients.
3.5.2 How have workloads changed?
We compared the activity in January 2016 with January 2017. The changes in workload
undertaken by clinicians are illustrated in Figure 3.2, 3.3 and Appendices 3 Figures A1-A5.
An increasing proportion of the GP workload is devoted to surgery consultations (48% of
their activities at the start of 2016 to 74% in 2017) and there has been a fall in their
administrative activities, telephone calls with patients, and home visits.
For ANPs the amount of patient contact has remained similar across the year, and they
now do results recording, currently about 20% of their activities (this activity was not
clearly recorded during the early months). PAs have taken on more patient telephone
calls and seen a reduction in the amount of administration and surgery consultations. It’s
not possible to judge changes in the PA results recording activities as these are often
ascribed to the GP who requested the tests. Considering just home visits, the number of
patients seen by GPs has fallen to about 10 per month, while ANPs have seen an average
of about 70 per month at a consistent level over the period.
As shown in Figure 3.4 below, the number of patients seen each month has been
increasing. GP surgery consultations have nearly doubled, from 1,355 in January 2016 to
over 2,593 in January 2017. ANPs see about 700 patients and PAs about 250 each month.
There are a number of possible reasons that might explain why GPs are now seeing more
patients. Firstly, the situation at the practice has stabilised following a rather chaotic
period in the first few months of the transition. Secondly, there has been a gradual
increase in the number of salaried GPs and a corresponding decrease in locums. Lastly,
there has been a shift of administrative activities, telephone calls with patients and home
visits to the other professionals.
28
Figure 3.4: Number of patient contacts by professional group (surgery consultations, home visits and medicine management), Oct. 2015 – Jan. 2017
3.5.3 How have referrals changed?
The total number of referrals has been increasing steadily from 300 in November 2015 to
nearly 400 in January 2017 (Figure 3.4). GPs make most of the referrals (over 300 in
January 2017) with ANPs and PAs making the remainder.
Figure 3.4: Number of referrals made by professional group, October 2015 to January 2017
0
500
1000
1500
2000
2500
3000
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
2015 2016 2017
GP ANP PA
0
50
100
150
200
250
300
350
400
450
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
2015 2016 2017
GP PA ANP Pharmacist Total
29
3.5.4 Emergency admissions data
Data were extracted from PMS using the current New Dyce Medical Practice patient CHI
list supplied by Practitioner Services. This was used to identify admissions to accident and
emergency at ARI or RACH or the AMIA (Acute medical Initial Assessment). AMIA
attendances are direct GP referrals that do not require emergency resuscitation. AMIA is
an assessment unit, so the patients are assessed, tests requested if required and then
decision made to admit or discharge. It is a bedded area, so although they use the
TrakED module in PMS, they are not recorded against the four hour standard.
The data originate from the period 1st July 2014 to 30th June 2016, so pre- and post-
changeover (Figure 3.5). It was not possible to exclude those patients that had joined
New Dyce from practices other than Brimmond and Gilbert Road, but it is thought this
would be a very small number of patients. The pattern in the number of admissions each
month shows quite a bit of variability and the number recorded during the transition
period (October – November 2015) does not seem unusual.
Figure 3.5: Number of New Dyce patient emergency admissions at ARI/RACH, July 2014 to
June 2016
0
20
40
60
80
100
120
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun
-16
Nu
mb
er
Month
AMIA (ED), ARI Em Dp, ARI Em Dp, RACH
30
Considering emergency admissions to the over-75s (Figure 3.6), New Dyce consistently
has the lowest rates among practices in the North Aberdeen cluster.
Figure 3.6: Emergency admissions to over-75s in North cluster Aberdeen, 12-month averages October 20161 to March 2017
1 Data before October 2016 are not shown as 12-month rates may be affected by transfer of patients
between Brimmond, Gilbert Road and New Dyce practice lists.
31
4 CONCLUSION AND RECOMMENDATIONS
The response from the evaluation has been generally positive, with high levels of
satisfaction from both patients and staff. This suggests that things are moving in the right
direction after a very challenging beginning. However, while patients were generally
positive about their experience of care, it must be noted that they were slightly less
content in their previous practices. As demonstrated using evidence from the Health and
Social Care survey reports for Brimmond and Gilbert Road practices, the overall care
provided was rated positively by 90% in Brimmond and 92% in Gilbert Road compared to
80% in New Dyce Medical Practice. This highlights the need for further improvement in
order to get to similar satisfaction levels. Possible areas for further development have
been identified as follows:
Triage: Introduce different triage arrangements, combination of guidelines for
reception/administration staff and a GP triage system for patients requiring
appointments. Patient allocation is usually conducted by administration staff with
no formal guidance, while patient responses show that they prefer to discuss their
conditions with clinical staff. One advantage of using GPs for triage would be to
increase the confidence of patients in their allocation to other professionals. Ideally
triage notes would be passed to the members of staff in consultation so patients
would not need to repeat their whole history.
Improve patient-facing systems: Problems with two systems were mentioned by
staff and patients, which need to be remedied. The automatic check in should be
adapted so the patient’s own name is clearly visible and the phone system should
be checked regularly to ensure callers can get through in a reasonable length of
time.
Training for receptionists: Staff at reception may benefit from further training in
dealing with people when under pressure. Customer/patient centred training would
help make the front facing as welcoming and professional as possible.
Reception area: Consider introducing a monitor with health information/TV/ music
to mask conversations at the front desk.
Communication with patients: To continue to improve patient understanding of
the new way of working further information could be given. For example, by using
signage in the practice to explain the different clinical roles (including
photographs) and/or circulating a newsletter to introduce new staff/explain roles.
Review workloads: it may be useful for all staff to meet regularly to consider
workload breakdowns and discuss whether these reflect the optimum use of time.
32
APPENDICES
Appendix 1: Sample of patient survey
33
34
35
Appendix 2: Comparative findings from recent Health and Social Care Surveys for Brimmond and Gilbert Road practices
% Positive Brimmond
2013/14
Gilbert Road
2015/16
It is easy to get through on the phone 85 86
Person answering the phone is helpful 92 97
Overall arrangements for getting to see a doctor 75 72
Overall arrangements for getting to see a nurse 75 85
Can see or speak to a doctor or nurse within 2 working days 84 80
Patients have enough time with doctors 92 95
Patients have enough time with nurses 97 99
Doctors talk in a way that helps patients understand their condition and treatment 93 94
Nurses talk in a way that helps patients understand their condition and treatment 92 89
Patients have confidence in doctors' ability to treat them 93 91
Patients have confidence in nurses' ability to treat them 98 95
Rating of overall care provided by GP practice 90 92
36
Appendix 3
Figure A1a: GP workload by activity (numbers of activities)
Figure A1b: GP workload by activity (percentages of activities)
37
Figure A2a: ANP workload by activity (numbers of activities)
Figure A2b: ANP workload by activity (percentages of activities)
38
Figure A3a: PA workload by activity (numbers of activities)
Figure A3b: PA workload by activity (percentages of activities)
39
Figure A4a: Pharmacist workload by activity (numbers of activities)
Figure A4b: Pharmacist workload by activity (percentages of activities)
40
Figure A5a: Practice nurse workload by activity (numbers of activities)
Figure A5b: Practice nurse workload by activity (percentages of activities)
41
New categories Original activities included
Home Visit Home Visit, Acute visit, Hotel Visit, Residential Home Visit
Admin Administration, Referral Letter, Repeat Issue
Other Other, Casualty Attendance, GOS18 Report, Hospital Admission
Telephone call with patient Telephone call from a patient, Telephone call to a patient, Triage
Clinic
Results recording
Surgery consultation
Third Party Consultation
Medicine Management
